Latrine utilization and associated factors among districts implementing and not-implementing community-led total sanitation and hygiene in East Wollega, Western Ethiopia: A comparative cross-sectional study

Introduction Discharge of excreta to the environment lead to surface and groundwater contamination and human exposure to disease-causing micro-organisms. There is limitation of evidences regarding the latrine utilization among community-led total sanitation and hygiene implemented and non-implemented districts of the East Wollega Zone. Hence, this study aimed to determine the magnitude and associated factors of latrine utilization among households in community-led total sanitation and hygiene implemented and non-implemented Districts in East Wollega Zone, Western Ethiopia. Methods A cross-sectional study was conducted. A Multi-stage sampling technique was applied to select the 461 households. Data were collected using interviews and observations guided by a pre-structured questionnaire. Data were entered using Epi Data and exported to SPSS software version 25 for data recording, cleaning, and statistical analysis. Bivariable logistic regression was run to identify the candidate variables at p-value <0.25. Variables that had associations with latrine utilization in the bi-variable analysis were entered together into multivariable logistic regression. An Adjusted odds ratio with a 95% confidence interval was calculated and P-value< 0.05 was used to declare a statistically significant association. Result The overall prevalence of latrine utilization was found to be 52.7% (95%CI:48%, 57.3%). Religion (AOR = 0.149;95%CI:0.044,0.506), education (AOR = 3.861;95%CI:1.642,9.077), occupation, absence of children <5 years (AOR = 4.724;95%CI:2.313,9.648), toilet cleaning (AOR = 10.662;95%CI:5.571,20.403), frequency of latrine construction (AOR = 6.441;95%CI:2.203,18.826), maintenance need (AOR = 6.446; 95%CI:3.023,13.744), distance from health institution (AOR = 0.987; 95%CI:0.978, 0.996), distance from kebele office (AOR = 6.478; 95%CI:2.137,19.635), and latrine distance from dwelling (AOR = 11.656; 95%CI:2.108, 64.44) were the factors associated with latrine use. Conclusion The latrine utilization in this study is low as compared to other studies. Religion, education, occupation, absence of children <5 years, toilet cleaning, frequency of latrine construction, maintenance need of the toilet, distance from health institution, distance from kebele, and latrine distance from dwelling are the associated factors of latrine utilization. Both households and health workers have to work together to improve latrine utilization and the safe disposal of children’s feces.

The authors received no specific funding for this work.

Competing Interests
Use the instructions below to enter a The authors have declared that no competing interests exist. Wollega health department. Also, letter of cooperation was taken from the zonal health department and oral permission was obtained from the district Health offices before the start of data collection. All necessary measures were made to guard against any form of harm and discomfort to the study subjects. The study purpose, risks, and benefits were explained in the local language for the participants. Their informed, voluntary, written and signed consent, in the end, was sought and participants thumb printed consent to participate in the study. Confidentiality was also guarded by making sure that the study participants will not be represented by their names. In addition, password Write "N/A" if the submission does not require an ethics statement.
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Consult the submission guidelines for detailed instructions. Make sure that all information entered here is included in the Methods section of the manuscript.  Background: Unsafe management and discharge of excreta to the environment lead to surface 29 and groundwater contamination and human exposure to disease-causing micro-organisms. There 30 is a paucity of the study that compares latrine utilization and associated factors among community-31 led total sanitation and hygiene implemented and non-implemented districts. Hence, this study 32 aimed to determine the magnitude and associated factors of latrine utilization among households 33 in community-led total sanitation and hygiene implemented and non-implemented Districts in East 34 Wollega Zone, Western Ethiopia. Unsafe management and discharge of excreta to the environment leads to surface and groundwater 63 contamination and human exposure to disease causing-micro-organisms (1,2). In other ways, a 64 latrine is a facility that is used for the safe disposal of human faeces and urine (3). It is the lowest 65 cost option that ensures a clean and healthful living environment both at home and in the 66 neighborhood of users (4). The use of accessible improved latrines in households and other settings 67 is the core strategy in water, sanitation, and hygiene (WASH) interventions and also to fight 68 neglected tropical diseases which are affecting one billion people globally (5). Further, effective 69 utilization of latrine can prevent diarrhea and malnutrition (6).

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There is confusion around the issue of how the accessibility of improved latrines is determined.

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Scholars argue that estimation of access to improved latrine needs to consider the chain of the  All households in the East Wollega zone were the source population for the study.

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All the households that have a latrine and were found in the selected districts of East Wollega were 139 the study population.

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The study inclusion criteria were all household heads who were greater than or equal to 18 years 143 and who resided in the area for at least six months.

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Exclusion criteria 145 All household heads who satisfied the inclusion criteria but who were away from home and/or 146 houses that were closed or could not be accessed at the time of the survey for two visits were 147 excluded from the study.

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The study sample size was calculated by using a double population proportion formula. The

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The data were collected using both quantitative and qualitative methods. The quantitative data 178 were collected through face-to-face interviews and observations using a pre-structured 179 standardized questionnaire adapted from the world health organization and the united nations After preparing the English version of the questionnaire, it was translated into the Afaan Oromo 220 language and then back-translated into English by another person to ensure that the originality and 221 meaning were retained. The pre-test of the questionnaire was done on 5% of the sample in the non-222 selected district to identify any ambiguity, consistency, and acceptability of the questionnaire.

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Then necessary corrections were made before the actual data collection to make it ready for final 224 data collection.

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Two days of training were given to the data collectors and supervisors on the topic, how to collect 226 the data, when and how to make an interview, and ethical issues emphasizing the importance of 227 the safety of participants and data quality. In addition, the quality of data was monitored frequently 228 both in the field and during data entry. This was done in the field through close supervision of 229 interviewers. Data quality tables were utilized. All completed questionnaires were examined for 230 completeness and consistency during the interview. An incomplete and unclearly filled 231 questionnaire was given back to the interviewer, and got complete questionnaires each day. Double 232 data entry using a programmed computer software package was done by two individuals.   households reported that they are located at a medium distance from the kebele office (Table 3). From the qualitative data, good progress in CLTSH implementation during the initial time was 289 identified. In this regard, the 35 years old male water, sanitation, and hygiene focal person said 290 that "CLTSH was reached almost all kebeles. However, there might be villages that are not 291 reached. During the first time, it was progressing well. But nowadays, it is not working as it is 292 impossible to hide. For the success of the session, you have to make them feel shame, fear, and 293 disgust. When the residents of the villages in which the approach is planned to be implemented 294 already get the information from their neighbor villages in which the CLTSH is implemented, you 295 cannot create those feelings." 296 A 34 male who was the coordinator of communicable diseases control-related activities at the 297 District level addressed that "the implementation of CLTSH during the initial time was good.

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Because it was possible to hide what was going to be done to accomplish the trigger target".

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However, as time goes on, the information disseminates rapidly and it became difficult to follow 300 the procedures." 301 A 34 male key informant added on this issue that "currently, the ODF replaced the CLTSH. The 302 concept is almost similar to that of CLTSH but it doesn't fully follow the CLTSH procedures. The health extension worker forwarded this idea. "It is impossible to hide the CLTSH procedures 310 because the neighboring villages can get the information once the CLTSH is implemented in 311 another village. Our community is interlinked with different social activities." One male key 312 informant responded on this issue as "in addition to information contamination, the CLTSH was 313 NGO driven initially. When that NGO phased out, the approach failed to function". It is when the 314 facilitators of CLTSH do not return to the villages for monitoring and follow-up after the ignition 315 phase of the CLTSH. In this regard, the 34 years old personnel from the district health official said 316 that "we had the problem of returning to the community to monitor the status of their performance.

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Once we facilitated the implementation of CLTSH in that community, we do not go for follow-up  Nonetheless, only five factors such as having children <5 years, cleaning of toilet, frequency of 335 latrine construction, maintenance need of the toilet, and distance from kebele office maintained a 336 significant association in multivariable logistic regression (Table 4).   The prevalence and associated factors of latrine utilization among households in the East Wollega

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Zone were assessed in this study. Accordingly, the prevalence of latrine utilization was found to 397 be 52.7% (95%CI:48%, 57.3%). It was 51.7% in CLTSH non-implemented villages while 53.7% 398 in CLTSH implemented villages. The value is almost similar to the national prevalence-50.02% 399 (22). It is also consistent with the study conducted in the Laelai Maichew district of Tigray in 400 which the latrine utilization of 54.9% among CLTSH implemented and overall latrine utilization 401 of 46. 8%-58.9% was observed (37, 42). However, the latrine utilization among CLTSH non-402 implemented villages in Laelai Maichew district, Tigray-38.7% (37) was found to be lower than 403 our finding. The current finding is also higher than the result of latrine utilization from the study 404 in South East Zone of Tigray-37.6% (43), and the study in Chencha District, Southern Ethiopia-405 31.08% (26). The discrepancy could result from the difference in socio-economic status, and 406 difference in study settings, and periods.

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The overall latrine utilization prevalence in our study is lower than the reports of latrine utilization

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The observed difference might be due to the difference in the way of latrine utilization 414 measurement, and study settings as some of the above studies were conducted in urban and semi-415 urban areas. In this regard, those households that had open pits without any form of the slab were 416 categorized as not utilizing the toilet in our study.

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Those households who were followers of the protestant religion were found to utilize their toilet 418 more likely than those in other religious categories (catholic, Muslim, and Adventist). As to the 419 authors' knowledge, a similar finding was not observed in the literature reviewed. However, the 420 possible explanation is that majority of the study households are protestant followers. Followers 421 of the catholic, Muslim, and Adventist religions were few among those studied households.

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Household heads who were able to write and read used their latrine about 3.86 times more likely  Occupation of the mother was another factor that was significantly associated with latrine 428 utilization in this study. Households with housewives were about two times more likely to utilize 429 latrines than those whose mothers were farmers in occupation. This finding agrees with the

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In this study, households that clean their toilet and have clean toilets had a high probability of 444 utilizing them than their counterparts. This is relevant to the studies conducted in Denbia district 445 (25) and Gurage (45). Although it is difficult to ascertain the direction of the association, 446 households that care for and clean their toilet might utilize it. It might be attributed to the fact that 447 using the unhygienically handled toilets is disgusting.

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The odds of latrine utilization was about 6 times more likely for those households that constructed  The odds of household latrine utilization is 6 times higher for the latrine that doesn't need 455 maintenance currently when compared to its counterpart. It might be difficult to utilize the latrine 456 which needs maintenance. Latrine whose slabs and superstructures are well-maintained promotes 457 its utilization by ensuring the privacy and safety of the users.

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The distance from the health institution is inversely associated with latrine utilization in this study.

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When the household distance from the health institution increases, latrine utilization decreases. In 460 another way, the odds of latrine utilization for near and medium households from the kebele office 461 were 6.5 and 4 times more likely than those too far from the kebele office respectively. This is 462 supported by another study conducted in Awabel District, Northwest Ethiopia. The households 463 near woreda health center had more chance of latrine utilization (46). This might be attributed to 464 the accessibility of health institutions and kebele offices that in turn could expose the households 465 to information, follow-up, and latrine utilization.

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Households whose latrine is found within ten (10) meters distance from the dwelling had 2.1 times 467 increased odds of latrine utilization as compared to their counterparts. A consistent result was 468 reported from the study in Awabel District, Northwest Ethiopia (46). This is because a distant 469 latrine location can reduce the chance of utilization.

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Unexpectedly, there is no significant difference in latrine utilization between CLTSH-471 implemented and non-implemented villages. This result is inconsistent with the finding of the 472 studies in Laelai Maichew district and Hawassa town (37, 40). The possible reason for the 473 discrepancy could be that currently CLTSH is not in active implementation in the current study 474 area as it was in the initial time. The status of CLTSH implementation described in this study is 475 ever implementation of CLTSH not necessarily the current implementation of CLTSH as this 476 approach is almost failed the current context.

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The strengths of this study are that latrine utilization and the associated factors are separately 478 determined and compared between CLTSH-implementing and non-implementing villages. On top 479 of this, it was a mixed method and tried to explore the CLTSH implementation status and the 480 challenges faced in the implementation through qualitative data collection methods. However, it 481 has its limitations. The first limitation is the cross-sectional nature of the study design which 482 couldn't ascertain the direction of association between the independent factors and latrine 483 utilization. Secondly, only two districts were involved which could affect the generalizability of 484 the findings to whole districts in the East Wollega Zone.

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The latrine utilization in this study was found to be lower as compared to many other studies in 487 different parts of the country and the open defecation-free mobilization. Religion, educational 488 status of the household head, occupation of the mother, absence of children <5 years, toilet 489 cleaning, frequency of latrine construction, maintenance need of a toilet, distance from health 490 institution, distance from kebele office, and latrine distance from dwelling were the factors that 491 found to affect latrine utilization. Hence, households need to maintain their toilets on time, 492 construct them proactively before they become out of service, clean their toilets frequently and 493 make them ready for utilization at all times. Besides, better if they construct a latrine at an 494 accessible distance from the dwelling in a manner that promotes its utilization and that does not 495 contaminate the groundwater sources. In addition to this, the adults in the household have to Sciences wrote the official letter to the East Wollega health department. Also, letter of cooperation 514 was taken from the zonal health department and oral permission was obtained from the district 515 Health offices before the start of data collection. All necessary measures were made to guard 516 against any form of harm and discomfort to the study subjects. The study purpose, risks, and 517 benefits were explained in the local language for the participants. Their informed, voluntary, 518 written and signed consent, in the end, was sought and participants thumb printed consent to 519 participate in the study. Confidentiality was also guarded by making sure that the study participants 520 will not be represented by their names. In addition, password protection of soft data and the use of 521 a key and lock for hard copy data was employed to guarantee confidentiality.   Authors' contributions 528 ATS conceptualized the study, wrote the proposal, analyzed the data, wrote the report, and led the 529 manuscript writing. DRT designed the methods and revised the proposal. AE and ETG engaged in 530 the design of the study and quantitative data analysis. MCC, JWF, and DSG designed the 531 qualitative data collection methods and revised the study proposal. BB, BRF, and ML analyzed 532 the data and prepared the manuscript. All authors read and approved the final manuscript.

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Our thanks go to Wollega University for giving us this opportunity to conduct scientific research 535 on the problems of the community. We would like to extend the special thanks to the East Wollega 536 zonal health department, health offices in the study districts, and primary health care unit directors 537 for giving us valuable information and permission to conduct the study. Finally, we thank the data 538 collectors, supervisors, and study participants for their cooperation.